Dear Coroner, Re: Regulation 28 Report to Prevent Future Deaths – Michael Leonard Moore who died on 17 September 2024.

Thank you for your Report to Prevent Future Deaths (hereafter “Report”) dated 11 September 2025 concerning the death of Michael Leonard Moore on 17 September
2024. In advance of responding to the specific concerns raised in your Report, I would like to express my deep condolences to Michael’s family and loved ones. NHS England is keen to assure the family and yourself that the concerns raised about Michael’s care have been listened to and reflected upon.

Your report raises concerns around the NHS being unable to deal with the significant increase in cancer referrals received, causing significant delays in waiting times for referral, which in turn impacts on those awaiting a diagnosis or undergoing surveillance, and those awaiting treatment.

Regional improvements

NHS England’s East of England regional colleagues have been advised by NHS Norfolk and Waveney Integrated Care Board (N&W ICB) that, to address the situation going forward, the following actions have been agreed with the Urology department at Norfolk and Norwich University Hospital:

1. A ‘capacity and demand’ review to identify gaps in service and move away from ad hoc Waiting List Initiatives (WLIs), with a view to meeting demand through recruitment to substantive posts. There is anticipated funding in place for the extension of a current locum post via the Cancer Alliance.
2. A ‘review and validation’ of the Category P2 list which is part of the National Clinical Prioritisation Programme, which is a technical and clinical review of patients waiting for elective care treatment. Categories P2-P4 relate to the period of time in which it would be clinically appropriate for a patient to wait for their procedure. Confirmed P2 cases should not wait longer than 4-6 weeks for treatment.
3. A ‘case by case’ review of patients awaiting both rigid cystoscopy and biopsy, as these represent the highest risk if delayed. These will be expedited as appropriate. National Medical Director NHS England Wellington House 133-155 Waterloo Road London SE1 8UG

5th November 2025

Alongside this, through the Clinical Harm Incident Group, Norfolk and Norwich University Hospital will continue to monitor potential or actual harm caused to long waiting patients that either have an emergency admission or die whilst on an elective waiting list or breach 104 days on their cancer pathways, providing the opportunity to identify emerging issues within specialties and address these. One of their local Patient Safety priorities for 2025/26 is emergency admissions of patients on a waiting list, and a thematic review is planned. More generally, the ongoing scrutiny of the waiting list, review of long waiting patients and scrutiny through validation continues.

National position

According to your Report, the evidence of the Hospital Trust at the inquest hearing included that the surge in cancer referrals has been widely reported across the NHS and that NHS England has acknowledged persistent capacity constraints across many providers. It is correct that the number of people referred for urgent cancer checks has increased significantly over the past decade. This reached 3.2 million in 2024-25, which was double the number of referrals in 2014-15. However, while there is ongoing work to deliver on the national cancer waiting times standards, performance has actually improved over the past two years. In March 2025, the NHS in England achieved its target for the Faster Diagnosis Standard (FDS) – this standard was that 77% of people should receive a diagnosis or ruling out of cancer within 28 days of an urgent referral. The NHS also met its interim 70% target, set in the 2024/25 Priorities and Operational Planning Guidance, for the 62 day standard (the standard is that 85% of people with cancer should start treatment within 62 days of an urgent referral). This improvement gave NHS England the confidence to set more stretching national targets in its 2025/26 Operational Planning Guidance. The new targets are 80% for the FDS and 75% for the 62 day standard.

I would also like to provide further assurances on the national NHS England work taking place around the Reports to Prevent Future Deaths. All reports received are discussed by the Regulation 28 Working Group, comprising Regional Medical Directors, and other clinical and quality colleagues from across the regions. This ensures that key learnings and insights around events, such as the sad death of Michael, are shared across the NHS at both a national and regional level and helps us to pay close attention to any emerging trends that may require further review and action.

Thank you for bringing these important patient safety issues to my attention and please do not hesitate to contact me should you need any further information.